The Overdose Epidemic in Nashville-Davidson County

Like many cities, Nashville is struggling with the challenges of a deadly drug overdose epidemic that has persisted in the United States for several decades. The overdose epidemic is a major public health crisis characterized by widespread drug overdose deaths fueled mainly by three classes of opioids: prescription opioids, heroin, and synthetic opioids like fentanyl. Fentanyl is a powerful synthetic opioid painkiller that is highly addictive, 100 times more potent than morphine and is commonly used as an additive to other street drugs.

The Centers for Disease Control and Prevention (CDC) have described this epidemic as three distinct waves. The figure below depicts the three waves of opioid-induced deaths per 100,000 persons in the United States. Each wave corresponds to a rise in deaths due to one of the three classes of opioids: prescription opioids, heroin, and synthetic opioids.

The first wave in the late 1990s was characterized by pharmaceutical companies aggressively marketing opioid prescription use. Commercial campaigns encouraged healthcare providers to prescribe opioids for pain management and sought to downplay patients’ risk of addiction to opioids such as OxyContin. These marketing efforts were later found to have been deceptive and unethical. The first wave also represented a failure by the Food and Drug Administration (FDA) to properly regulate the pharmaceutical industry. These actions led to a spike in opioid prescriptions and a rise in people living with opioid use disorder (OUD) or addiction. An increase in overdoses and deaths ultimately followed.

 _{Read more about the FDA's role in the opioid crisis -  AMA Journal of Ethics}  

The second wave, which began in 2010, is defined by a shift in the use of prescription opioids to heroin. This shift led to a surge in the mass production and distribution of more affordable alternatives to prescription opioids, like heroin, leading to a rise in deaths associated with heroin. During this period, the number of people grappling with opioid dependence increased dramatically. Additionally, the 2017 National Drug Threat Assessment from the Drug Enforcement Administration (DEA) highlights that, during this period, Mexican and Colombian transnational criminal organizations (TCOs) replaced Southeast Asian TCOs as the primary sources of heroin. This shift contributed to increased heroin purity and availability in the U.S.

The third and ongoing wave began in 2013 and is driven by fentanyl-mixed heroin, fentanyl analogs, and other illicit synthetic opioids. Deaths rose dramatically in 2013 and again during the COVID-19 pandemic. In 2021, Nashville-Davidson County recorded 665 suspected opioid-related deaths, marking a 40% increase compared to 2019. Of these opioid-related deaths, 76% were linked to fentanyl. Similar spikes in deaths linked to fentanyl have been reported at the national level, highlighting the gravity of the current situation.

 ^{Continue reading about the 3rd Wave -  Where do we stand?}  

Anesthesiologists describe opioids as medications used to treat persistent or severe pain. Such pain may be experienced by people suffering from chronic cancer, recovering after surgery, or following severe injury. Opioids prevent pain signals from reaching the brain by binding to various opioid receptors which simultaneously causes an intense euphoria or "high".

Opioid use disorder (OUD) is defined as a condition when a person is unable to control their opioid use or when it interferes with their daily life. OUD is the result of a brain chemical imbalance that leads a person to develop a tolerance to and dependence on opioids. People with OUD may continue to use drugs despite the risk of severe harm and even when there is a strong desire to quit.

The most common and severe clinical symptom of OUD is physical dependence. Physical dependence can occur in a matter of days or weeks. In opioid dependence, a negative reaction (withdrawal) occurs when an opioid is discontinued. Severe withdrawal symptoms are one of the biggest obstacles people face when attempting to stop or quit opioid use. A desire to prevent withdrawal symptoms forces users to seek and use more opioids.

The withdrawal reaction to opioid cessation is a complex process involving several parts of the brain. An absence of opioids in the system of someone with OUD can set off a chain reaction that dysregulates various brain chemicals and leads to a reduction of dopamine (the "feel-good hormone"). These chemical changes lead to severe withdrawal symptoms that can be difficult to manage such as anxiety, depression, constipation and nausea, severe muscle and bone pain, restlessness, and severe cravings or drug-seeking behavior.

In addition to physical dependence, people can develop opioid tolerance where repeated use of an opioid leads to a reduced response to it. This leads users to take increasing amounts of opioids to achieve the same effects, e.g., pain relief or euphoric effects. Like dependence, tolerance is also the result of a brain chemical imbalance. In opioid tolerance, these changes decrease the brain’s responsiveness to dopamine.

 ^{Learn more:  Opioid Use Disorder  and  Opioid Basics}  

While brain abnormalities that result from opioid use can be treated through medication-assisted treatment (MAT), the environmental factors and genetic makeup that influence OUD are more complex and difficult to address. Factors such as stress and social pressures might lead individuals to relapse days, weeks, months, or even years after opioid cessation.

 _{For SUD or OUD prevention, intervention, or treatment resources see:  Community Resources}  

This public health crisis has been worse in certain low-income communities and rural areas, and individuals with a history of mental illness or substance use disorder (SUD), indicating a complex interaction between individual and environmental factors. In recent years, the environments where people are born, live, learn, work, play, worship, and age are increasingly thought to be involved in a variety of health outcomes. These conditions are called social determinants of health (SDOH).

Compelling evidence suggests that socioeconomic factors in particular (e.g., income, educational attainment, wealth, insurance) are contributors to a wide range of positive and negative health outcomes, including OUD or the broader SUD. For example, unemployment, poverty (household income within 100% of the poverty threshold), and criminal justice system involvement are generally associated with increased use of illicit drugs and SUD. Furthermore, economic insecurity among those who experience unemployment or poverty face higher stress, limited access to healthcare, and an increased risk of opioid overdose. In addition, homelessness raises the chances of a person being exposed to harmful substances, feeling socially isolated, and experiencing high levels of stress, all while weakening the strength of their social support networks.

Community factors like neighborhood poverty and violence, lack of housing, residential segregation, compromised public safety, and limited access to healthcare or disparities in insurance status are associated with increased rates of substance use. Overdoses, in turn, negatively affect communities by increasing the burden on families and caregivers. Youth are particularly vulnerable to these kinds of environmental conditions. Adverse childhood experiences (ACEs), such as physical, emotional, or sexual abuse, and parental substance abuse, have long-lasting impacts on physical and mental health. Research shows that youth who are exposed to parental illicit substance use, witness an overdose, or experience other ACEs are more likely to engage in substance misuse as they cope with adversity.

Cultural attitudes and even historical U.S. drug policies have reflected the misconception that drug addiction is a personal failing rooted in bad choices and a lack of willpower. These attitudes and policies can reinforce systemic barriers to treatment and harm reduction services.

As early as the 1970s, drug abuse was declared "Public Enemy #1" by the U.S. government. This motivated the War on Drugs and the creation of the Drug Enforcement Administration. This approach prioritized law enforcement, criminalization of drug use, and strict drug control measures. Mass incarceration was a result of this approach, disproportionately impacting certain communities and contributing to the criminalization of drug addiction (SUD). These efforts intensified during the 1980s. During this period new anti-drug laws were passed, and the initiation and expansion of prison and police programs would cause prison populations to double across the country and disproportionately impact African American communities. By 1989, one in every four African American males between the ages of 20-29 were incarcerated, on probation, or parole. By 1995 this statistic increased to one in three.

Recent changes in US drug policy and the 2017 declaration of the overdose crisis as a public health emergency have marked a shift in addressing the crisis, from punitive measures to a public health approach that prioritizes harm reduction, evidence-based prevention programs, surveillance, and expanded access to medication-assisted treatment (MAT). These policy changes are part of a larger evolution in knowledge and attitudes among the medical community and general public toward recognizing SUD/OUD as a medical issue demanding a public health response.

Recent legal settlements with pharmaceutical giants like Purdue Pharma, Mallinckrodt, and Johnson & Johnson highlight the estimated $10 billion cost of the overdose epidemic in America. This price tag is very likely an underestimation, for example, a study in 2017 found that the estimated cost of health care, criminal justice, lost productivity, and reduced quality of life was $1.02 trillion.

Since 2021, this crisis has claimed the lives of more than 100,000 persons and disrupted the lives of countless more. Life expectancy in the U.S. has leveled or even decreased in certain regions due in part to the overdose crisis. A new understanding of the true impact and far-reaching consequences endured by communities, families, and individuals have triggered calls for a radical rethinking of the public health approach.

Communities around the nation are innovating as public health agencies are working together to develop flexible, effective plans to address the crisis in their own communities. A new framework emphasizes the broader social and environmental factors in public health issues such as the overdose crisis. The framework, called Public Health 3.0, takes a multi-sector collaborative approach to better respond to the evolving health needs of communities.

 ^{Learn more about -  Public Health 3.0}  

The Metro Public Health Department (MPHD) adopted the Public Health 3.0 framework in addressing the overdose crisis. Partnerships between public health and safety agencies, healthcare providers, forensic services organizations, and community-based organizations bring awareness, resources, and unique expertise to the complex and dynamic overdose epidemic. MPHD in collaboration with Nashville Fire Department Emergency Medical Services (NFD-EMS), Metro Nashville Police Department (MNPD), and the Medical Examiner's Office, are leading efforts to address the overdose crisis in Nashville-Davidson County, with numerous community-based organizations playing a vital role in the response.

During the COVID-19 pandemic, overdose deaths spiked across the United States, leading some experts to believe that the overdose epidemic is entering a fourth wave. This new phase appears to be characterized by the widespread use of stimulants, sedatives, and other illicit substances alongside opioids.

The use of more than one substance during a short period is not new or uncommon. However, a large increase in the detection of opioids mixed with methamphetamine, cocaine, and benzodiazepines is creating a complex and dangerous situation. Effective treatments for opioid use disorder are not effective for stimulant addiction or other forms of substance use disorder. Additionally, a combination of illicit substances, or polysubstance use, increases a person's risk of overdose and may make lifesaving overdose medications like naloxone less effective.

The following section will summarize the local overdose crisis in Nashville-Davidson County with data from the following three sources: medical examiner death records, NFD-EMS responses, and syndromic surveillance system for emergency department visits.

 _{All data presented are provisional, subject to change, and may also differ from other publicly available data sources.} 

Since 2020, there have been over 2,500 suspected fatal overdose deaths in Nashville-Davidson County. A concerning revelation highlighting the epidemic's upward trajectory shows us that deaths occurring during or after 2020 accounted for over 50% of all suspected overdose deaths since 2010.

Fentanyl is the leading contributor to overdose deaths in Nashville-Davidson County, however, cocaine and methamphetamine are frequently detected in conjunction. In 2018, fentanyl was detected in over 50% of all suspected fatal overdoses for the first time. The detection of fentanyl has since peaked during the pandemic at 76% and has remained relatively unchanged since. At the same time, the number of fatal overdoses has increased each year since 2016. In 2022, there were a total of 748 suspected fatal overdoses which represented a 2-fold increase from 2018 and a 20% increase from 2020. The majority of deaths from 2018-2022 occurred among White persons (71%), males (69%), and people between the ages of 25-54 (75%) years. However, a closer look at the data reveals that overdose deaths among Black/African American communities are on the rise, a pattern that is consistent with national trends.

The overdose epidemic has evolved through both old and new influencing factors. One such factor is the shift of substances involved in overdose deaths throughout the decades. Our partners at the Medical Examiner's Office consistently monitor for substances through routine toxicology reports among recently deceased. Through this routine surveillance, emerging substances that make their way into our community can be identified. However, early detection of new substances poses an incredible challenge to public health data systems. Traditional testing and monitoring systems struggle to keep up with the rapidly changing nature of the drug market.

 ^{Read about our latest drug advisory  here .} 

NFD-EMS responses peaked during the pandemic at about 5,800 responses in 2020, representing an 88% increase from 2016 and about a 50% increase from 2018. However, 2021 was the first time in the previous 5 years in which NFD-EMS responses did not increase. The average number of NFD-EMS responses per year for suspected overdoses has been 5,700 responses since 2020. The majority of people who required NFD-EMS response from 2018 to 2022, were White persons (50%), males (60%), and people between the ages of 25-44 (50%).

There have been approximately 13,000 emergency department (ED) visits for suspected overdoses from 2016 to date, of which 66% occurred during or after the COVID-19 pandemic. ED visits peaked in 2020 at about 2,600 cases and have remained relatively stable at around 2,400 cases per year since. The majority of ED visits from 2018 to 2022, were White persons (64%), males (68%), and people between the ages of 25-44 (55%) years old.

 2024 Quarter 4 Drug Overdose Report is Available 

As the community’s chief health strategist (per the Public Health 3.0 Framework), MPHD facilitates the implementation of a county-wide overdose prevention and reduction strategy. This work is in collaboration with partner public health and safety agencies, healthcare providers, forensic services organizations, and community-based organizations.

The goal of this collaboration is to align the coordination of resources and strategies across multiple organizations and sectors of the community, improve data and information sharing, and make near real-time data available to inform prevention actions. For example, the Metro Nashville Police Department (MNPD) and Nashville Fire Department Emergency Medical Services (NFD-EMS) partner with the Mental Health Cooperative (MHC) to offer post-overdose linkage to care services. MNPD and NFD-EMS partner with the Regional Overdose Prevention Specialists (ROPS) program to deliver the “Leave Behind” program and offer other geographically targeted harm reduction and prevention education services. Prevention specialists in several other partner organizations deliver culturally and linguistically focused prevention programs and facilitate linkage to care and treatment services.

Within the community, MPHD's Behavioral Health and Wellness (BHW) Division focuses on addressing the behavioral aspects of substance use, recognizing that SUD is a treatable mental illness that affects a person's brain and behavior. The BHW division prioritizes the needs of community members by meeting people where they are and providing resources for prevention, intervention, and postvention to improve the mental and behavioral welfare of Nashville-Davidson County residents. This division also provides non-emergent substance misuse and brief mental health screening, recommendations, and referrals for insured and uninsured adults. In direct response to the opioid epidemic, the BHW division promotes awareness within the community, facilitates training with community members, and collaborates with community partners to reduce overdoses. Additionally, this division manages a community safety & violence interruption program to address the impact of violence in the community.

Furthermore, MPHD's Division of Epidemiology has a dedicated team responsible for implementing overdose monitoring and response (OMAR) activities, including public health surveillance and program evaluation functions. The division also provides support for the development and implementation of OMAR plans in surrounding counties that, together with Davidson County, constitute the state-designated Mid-Cumberland Region High Impact Area (MCR HIA). 

 ^{Learn more about  The High Impact Program of Middle-TN}  

Consistent with MPHD's approach, the Division of Epidemiology facilitates community-wide efforts to assess and evaluate mental health conditions including drug overdoses. The division has worked to develop a data hub for the overdose monitoring and response community in Davidson County and the mid-Cumberland region by assembling and compiling data from a variety of sources including but not limited to partners, research institutions, publicly available and customized analyses, and reports from government agencies. The diversity of data sources provides a wide range of indicators to guide, monitor, and assess overdose prevention strategies and to track responses to both suspected fatal and nonfatal overdose events county-wide. The following are some of the sources of overdose prevention data that are currently being monitored.

Data sources:

• NFD-EMS information system - Suspected overdose incidents with EMS response and referrals to care
• ESSENCE database - Syndromic surveillance of emergency/urgent care
• Medical Examiner databases - All coroner and ME reports; including toxicology data
• Drug Overdose Reporting (DOR) database - Tennessee system for reportable overdose events
• Overdose Detection Mapping Application Program (ODMAP) - Map of first responder data useful for anomaly detection and hotspot analysis
• Public health death files - From vital records provided by the state or accessed through CDC-hosted platforms
• CDC's Youth Risk Behavior Surveillance System (YRBSS) – Available for Davidson County since 2019, data about substance use patterns & adverse childhood experiences among high school students. 
• Linkage to Care reports (EMS, MH Coop) 
• Naloxone distribution (Street Works and NFD/EMS information system)
• Needle exchange (Street Works)
• Controlled Substance Monitoring Database (TDH – available upon request) 
• Partner-provided intelligence - Offered/gathered as part of collaborative spike/anomaly investigations and responses, hotspot analytics, and program monitoring and evaluation efforts

MPHD provides publicly available information on resources, prevention tips, naloxone (Narcan), syringe services program, SPIKE Auto Text Program, data reports, and public health advisories that can be found  here . The MPHD's Division of Epidemiology continues to dedicate efforts to the development of a more comprehensive set of quantitative and qualitative indicators by identifying supplementary data sources, introducing new data collection tools when necessary, and onboarding additional community partners.

Now in its third year, National Fentanyl Awareness Day brings together individuals, parents, teachers, corporations, influencers, community groups, and government entities to help put an end to this emergency.

Last year, over 70,000 Americans fatally overdosed on illegally made fentanyl. Fentanyl is now found in fake pills and many street drugs, but users are often unaware that their drugs contain the potent opioid. This is an urgent public health crisis that puts all of us, and our loved ones, at risk. We all must play a role in preventing further tragedies. 

Spread the word to save a life.

IOAD is global event held on August 31st, it is the world's largest annual campaign to end overdose, remember those we have lost to an overdose, acknowledge the grief of the family and friends left behind, and renew our commitment to end overdose and related harms.

Metro Public Health Department's Division of Behavioral Health & Wellness are hosting a summit this year to help raise awareness and explore the vital links between mental health and opioid misuse. The summit titled - Beyond The Crisis: An Overdose Awareness Briefing - will have expert presentations on the latest data and benefits of Medication-Assisted Treatment (MAT), and the importance of wrap-around services like counseling and addressing issues around the unhoused. This briefing will explore these topics within the framework of MPHD’s Opioid Care Process Pilot, designed to develop a comprehensive Opioid Care System.

Date - 8/29/2024, Time: 2:30pm - 4:30pm, Location: MPHD Lentz Building, 2500 Charlotte Ave

Substance use disorder affects people from all walks of life and all age groups. If you, your family or friends are directly affected, know that there is help available and that you are not alone. The following are resources that you can use to inform yourself and get the help you need.

• Neglecting responsibilities at school, work, or home
• Legal trouble such as DUI or disorderly conduct

• Bloodshot eyes, abnormally large or small pupils
• Change in appetite, sleep behaviors, physical appearances such as lack of grooming/hygiene, poor skin tone, and tired appearance

• Drop in attendance or performance at school or work
• Engaging in secretive behavior or increased desire for privacy
• Drastic changes in relationships
• Poor financial management, such as not paying bills on time or increased spending

• Unexplained change in personality or attitude
• Random mood swings, irritability, space-out, or angry outbursts
• Increased anxiety, paranoia, or fearfulness with no cause

Call 911 immediately if someone is experiencing any of the following symptoms, be sure to follow directions given by the 911 dispatcher and monitor the individual until first responders arrive:

• Their face or hands are extremely pale, cold, and/or feels clammy to the touch
• Pupils extremely constricted/small
• Their body goes limp
• Their fingernails or lips have a purple or blue discoloration
• They start vomiting or making gurgling noises/snoring sounds
• They are unresponsive, cannot be awakened or unable to speak
• Their breathing or heartbeat slows or stops
• If available, treat the person with naloxone to reverse an opioid overdose
  • If not responsive after 2-3 minutes, administer a second dosage of naloxone
• If naloxone is unavailable or unsuccessful, perform CPR until paramedics arrive
• Once responsive, lay the person in the recovery position until help arrives
  • Put the person slightly on the left side so that their body is supported by a bent knee with their face turned to the side and bottom arm reaching out to stabilize the position

 ^{Adapted from: Tennessee Department of Mental Health & Substance Abuse Services and The United States Drug Enforcement Administration} 

Naloxone is an approved medication by the Food and Drug Administration (FDA) that rapidly reverses an opioid overdose. While naloxone can quickly restore breathing, naloxone may be ineffective against other illicit substances such as xylazine or "tranq".

Website -  https://starsnashville.org/rops/ 

Website -  https://www.redcross.org/take-a-class 

CORT is a free and confidential resource to help find drug and alcohol treatment for individuals who are at risk of an overdose. The service is offered free of charge regardless of health insurance status.

Tennessee REDLINE provides accurate, up-to-date alcohol, drug, problem gambling, and other addiction information and referrals to all citizens of Tennessee regardless of insurance status.

Website -  https://www.tn.gov/opioids/treatment/how-to-get-help.html 

A comprehensive, confidential and anonymous resource for people seeking treatment for mental & substance use disorder in the US & territories. Facilities are updated on a yearly basis ensuring you get the most up-to-date treatment facilities information.

Website -  Findtreatment.gov 

A 24-hour free and confidential treatment referral and information about mental health and substance use disorder, prevention, and recovery in English & Spanish

•  Opioid Treatment Directory  - SAMHSA

A growing body of research highlight the importance of capitalizing on opportunities to prevent and intervene early in an adolescent's life to prevent substance use disorder and related behavioral health problems.

Nashville Thrives Coalition is a SAMHSA grant funded initiative with partnerships across 15 sectors whose mission is the make the health and wellbeing of ALL Nashvillians our city's highest priority. Below is a link to the coalition's program referral system.

Prevention Program Referral System -  https://redcap.link/Prevention_Referral_System 

•  Behavioral Health and Wellness Services 
•  Opioid Information 
•  Naloxone Information 
•  Syringe Services Program (SSP) 
•  SPIKE Auto-Text Program 
•  Drug Overdose Quarterly Reports --- 2024 Q4 Available 

•  Opioid Overdose Toolkit 
•  Medicated Assisted Treatment 
•  What is Substance Abuse Treatment 

•  Recovery Is Possible 

Last Updated: 2/4/2025

 ^{Disclaimer: The findings, conclusions, and opinions of authors contributing to this story map are those of the authors and do not necessarily represent the official position of the Metro Public Health Department, or the authors’ affiliated institutions. Links embedded in this story map may lead to non-metro health sites, however, they provide additional information that is consistent with the intended purpose of this story map. Linking to non-metro health sites does not constitute an endorsement by the Metro Public Health Department or affiliated institutions. Many of the images used in this story are stock photographs. The images are for illustrative purposes only.} 

 _{Preferred Citation: Overdose Monitoring and Response Team. (2024). The Overdose Epidemic in Nashville-Davidson County. Metro Public Health Department.  https://arcg.is/iSeDv0}